STATE OF CALIFORNIA· DEPARTMENT OF TRANSPORTATION

CHANGE ORDER

Sheet 1 of

CEM-4900 (REV 2/2014) Change Requested by: D Engineer C8] Contractor

FEDERAL No(s). CHANGE ORDER No. SUPPLEMENT No. CONTRACT No. Co-Rte-PM

TO , contractor

You are directed to make the following changes from the plans and specifications or do the following described work not included in the plans and specifications for this contract. NOTE: This change order is not effective until approved by the Engineer.

Description of work to be done, estimate of quantities and prices to be paid. (Segregate between additional work at contract price,

agreed price and force account.) Unless otherwise stated, rates for rental of equipment cover only such time as equipment is actually

used and no allowance will be made for idle time. The last percentage shown is the net accumulated increase or decrease from the

original quantity in the Bid Item List.

At the contractor's option, accept payment deductions for HMA pavement smoothness that is noncompliant with the pavement smoothness mean roughness index (MRI) requirement in Section 39-2.02A(4)(i)(iii) Pavement Smoothness, of the 2015 Standard Specifications, or Section 39-l.01D(9)(c) Pavement Smoothness of the 2010 Standard Specifications, the contractor agrees to accept payment deductions as shown in the tables below for each HMA noncompliant 0.1-mile section within the MRI acceptable range listed in the table. Mandatory pavement smoothness corrections are required to meet the MRI acceptable ranges listed in the tables below before payment deductions may be applied.

For pavement smoothness 0.1-mile segments that do not meet the specified 75 MRI requirement, payment deductions will be taken as shown in the table:

HMA Pay Deduction for MRI Requirement 75 in/mi

HMA thickness MRhx1sT MRI Acceptable Range

(in/mi) Payment Deduction per 0.1 mi segment

< 0.30 foot < 135 in/mi 75.1 to 90.0 (MRhINAL - 75.0) x $90.00)

< 0.30 foot 2:: 135 in/mi MRhARGET to (MRITARGET + 15.0) (MRlFINAL - MRI TARGET) x $90.00)

Where:

MRlrARGET = (0.3 X MRIEXIST) + 35 in/mi MRI EXIST is defined as better of (1) the existing pavement MRI or (2) the MRI taken after prepaving grinding or structural repairs, such as remove and replace asphalt pavement or HMA leveling course, was performed. MRlFINAL is defined as the MRI after paving is completed or after pavement smoothness corrections have been made. MRIExrsT cannot be determined use 75.1 to 90.0 range for payment deduction calculation

For pavement smoothness 0.1-mile segments that do not meet the specified 60 MRI requirement, payment deductions will be taken as shown in the table:

HMA Pay Deduction for MRI Requirement 60 in/mi

HMA thickness MRhx1sT MRI Acceptable Range

(in/mi) Payment Deduction per 0.1 mi se2:ment

2:: 0.30 foot < 165 in/mi 60.1 to 80.0 (MRIFINAL - 60.0) X $142.50

2:: 0.30 foot 2:: 165 in/mi MRlTARGET to (MRITARGET + 20.0) (MRIFINAL - MRITARGET) x $142.50

Where:

MRITARGET = (0.09 X MRIEXJST) + 45.5 in/mi MRI8xrsT is defined as better of (1) the existing pavement MRI or (2) the MRI taken after prepaving grinding or structural repairs, such as remove and replace asphalt pavement or HMA leveling course, was performed. MRIFINAL is defined as the MRI after paving is completed or after pavement smoothness corrections have been made.

MRIExrsT cannot be determined use 60.1 to 80.0 range for payment deduction calculation

CPD 19-6, "Hot Mix Asphalt Pavement Smoothness" Attachment 2

Payment Adjustment at Agreed Lump Sum The contractor shall credit the state the agreed lump sum of$ ____ . The sum constitutes full and complete compensation for this change.

Time Adiustment There will be no time adjustment by reason of this change.

Insert the following paragraph if there was a prior PCRfor H.MA pavement smoothness This change order resolves potential claim record No. __ , dated [insert date].

Estimated Cost: D Increase 181 Decrease $

No Ad"ustment

SIGNATURE (PRINT NAME AND TITLE) DATE

SIGNATURE (PRINT NAME AND TITLE) DATE

SIGNATURE (PRINT NAME AND TITLE) DATE

We, the undersigned contractor, have given careful consideration to the change proposed and agree to provide equipment, furnish materials, and perform the work specified above, and will accept as full payment the prices shown above. NOTE: If you do not sign this order, you are directed to proceed with the ordered work. You may file a Request for Information within the time specified.

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For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233, ADA Notice TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.

CPD 19-6, "Hot Mix Asphalt Pavement Smoothness" Attachment 2